Insuring Lawyers| Attorneys Advocate program, professional liability insurance law, and contemptible public liability insurance

Firm/ Applicant Name* :

Email Address :

Principal Business Address :

Phone :
Fax :
Effective Date Requested :

City :

State :

County :

Zip :

Please List all the attorneys practicing on behalf of your firm. Add attachments if necessary

Attorney Name	Social Security Number	Years in private practice	Designation Code		Current Legal Malpractice Insurance Carrier	Retroactive Date

Designation Code : E = Member/Employee of the Firm, OC = Of Counsel/Independent Contractor and F= Full Time, P= Part Time ( 26 hours or fewer per week)

Have any members of your firm been reprimanded, censured, suspended or disbarred within the past five (5) years?
If YES, provide full details on your letterhead.

Yes No

Have any professional liability claim(s) or suit(s) been made against the applicant firm or any attorney(s) in the applicant firm or former attorney(s) in the applicant firm within the past five years?
If YES, complete the Claim Supplemental Application.

Yes No

After inquiry, are you or any attorney in your firm aware of any circumstances, incidents, acts or omissions that has led to a professional liability claim that has not yet settled or which could lead to a professional liability claim being made against your firm?
If YES, complete the Claim Supplemental Application.

Yes No

Current Limit of Liability :

Limits Desired :

Current Deductible :

Deductible Desired :

Expiring premium :

Please provide the percentage of the gross billable dollars allocated to each area of practice. Please round to the nearest whole number. Total must be equal to 100%.